Provider Demographics
NPI:1265242622
Name:GLENNON-BOATRIGHT, KRISSELLA LEE (MFT, PCC, CWC)
Entity type:Individual
Prefix:MRS
First Name:KRISSELLA
Middle Name:LEE
Last Name:GLENNON-BOATRIGHT
Suffix:
Gender:F
Credentials:MFT, PCC, CWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6363 ALTA VISTA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4745
Mailing Address - Country:US
Mailing Address - Phone:805-791-4428
Mailing Address - Fax:
Practice Address - Street 1:2021 SPERRY AVE
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-7408
Practice Address - Country:US
Practice Address - Phone:805-699-1263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16206101YP2500X
CA2508C30AF6171400000X
CA145852106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171400000XOther Service ProvidersHealth & Wellness Coach